Client Name: <PtName>	DOB: <PtDoB>	
Contact Number: <PtPhoneMob>	Gender:<PtSex>	
Address: <PtStreet> , <PtCity>	<PtCity>, <PtPostcode>	
Country of Birth: 	Language:                      	
Aboriginal or Torres Strait Islander: oYes  o No	Interpreter Required___	
Emergency Contact: Name: _________________________ Ph:___________________
Relationship to Client:  _________________________ 

Medications:_____________________________________________________________________
______________________________________________________________________________________
Patient has own means of transport    o    Yes    o  No    Current walking distance______
Is patient eager to participate              o    Yes    o  No
GP approval to participate in pulmonary rehabilitation      o   Yes        o   No
GP Name:<DrName> 			Ph: <DrPhone>
Address:<DrStreet> , <DrCity> , <DrPostcode> 
Signature: ________________________________Date:<TodaysDate>